Information Collection

Crisis Next Door Campaign Assessment

IC 238053 under ICR 201806-0920-001 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0572 Crisis Next Door Campaign Assessment	Form and Instruction
0920-0572 Crisis Next Door Screener Attachment 3 - Screener_20SEP2019.docx	Form and Instruction
0920-0572 Crisis Next Door Questionnaire Attachment 3 Survey Questionnaire Revised 09OCT2019.docx	Form and Instruction
Link to Crisis Next Door (CND) Videos.docx Crisis Next Door (CND) Videos	IC Document
Attachment 2 - Consent Form_20SEP2019.docx Consent Form	IC Document
HMTSExpeditedReviewForm - Crisis Next Door_FINAL.pdf HMTS Expedited Review Form	IC Document

IC Title:

Crisis Next Door Campaign Assessment

Agency IC Tracking Number:

09209-0572-19BRS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0572	Crisis Next Door Screener	Attachment 3 - Screener_20SEP2019.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Crisis Next Door Questionnaire	Attachment 3 Survey Questionnaire Revised 09OCT2019.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,315

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,315	6,315
Annual IC Time Burden (Hours)	774	774
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crisis Next Door (CND) Videos	Link to Crisis Next Door (CND) Videos.docx	10/09/2019
Consent Form	Attachment 2 - Consent Form_20SEP2019.docx	10/09/2019
HMTS Expedited Review Form	HMTSExpeditedReviewForm - Crisis Next Door_FINAL.pdf	10/09/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.